Anaes · Ophthalmic anaesthesia
Open-globe and penetrating eye injury anaesthesia
Also known as Open-globe and penetrating eye injury anaesthesia
Exam-exhaustive open-globe anaesthesia including suxamethonium debate for ANZCA Final.
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Red flags
- Aspiration risk usually outweighs brief sux IOP rise.
- Modern consensus: sux not absolute contraindication.
- Rocuronium RSI with sugammadex is an alternative.
- Avoid coughing/bucking more than obsessing over ~10 mmHg.
- Deep smooth airway management is the priority.
Meet the patient
A 28-year-old arrives in the emergency theatre two hours after a meal with a penetrating nail injury to the right eye. The globe is lacerated, the surgeon wants to operate now, and the stomach is full. Your registrar says suxamethonium is contraindicated in the open globe.[1][4]
The two questions that decide the induction: what kills this eye — a brief pressure rise or a cough and a vomit? and what kills this patient — aspiration or the eye? The modern answer is that aspiration and bucking are the dominant threats, and the registrar's absolute rule is out of date — the teaching on succinylcholine and the open eye has been traced through the literature and shrunk to size.[1][4]
References7ShowHide
- [1]Vachon CA, Warner DO, Bacon DR Succinylcholine and the open globe. Tracing the teaching Anesthesiology, 2003.PMID 12826863
- [2]Cunningham AJ, Barry P Intraocular pressure--physiology and implications for anaesthetic management Canadian Anaesthetists' Society journal, 1986.PMID 3516335
- [3]Kelly RE, Dinner M, Turner LS, et al. Succinylcholine increases intraocular pressure in the human eye with the extraocular muscles detached Anesthesiology, 1993.PMID 8239012
- [4]McGoldrick KE The open globe: is an alternative to succinylcholine necessary? Journal of clinical anesthesia, 1993.PMID 8442960
- [5]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in bleeding trauma patients (CRASH-2): a randomised, placebo-controlled trial Lancet (London, England), 2010.PMID 20554319
- [6]Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial Lancet (London, England), 2011.PMID 21439633
- [7]Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial Lancet (London, England), 2008.PMID 18479744